Schizophrenia Spectrum and

UNIT 6 SOMATIC SYMPTOMS AND Other Psychotic Disorders

RELATED DISORDERS*

Structure
6.0 Introduction
6.1 Somatic Symptom Disorder
6.2 Illness Anxiety Disorder
6.2.1 Clinical Picture
6.2.2 Statistics
6.2.3 Causal Factors
6.2.4 Treatment
6.3 Conversion Disorder (Functional Neurological Symptom Disorder)
6.3.1 Clinical Picture
6.3.2 Statistics
6.3.3 Causal Factors
6.3.4 Treatment
6.4 Psychological Factors Affecting Medical Condition
6.5 Factitious Disorder
6.6 Distinguishing between Conversion Disorder, Factitious Disorder, and
Malingering (faking)
6.7 Summary
6.8 Keywords
6.9 Review Questions
6.10 References and Further Reading
6.11 References for Images
6.12 Web Resources
Learning Objectives
After reading this Unit, you will be able to:
Explain the nature of somatic symptoms and related disorders;
Discuss the clinical aspects of somatic symptom disorder;
Examine the causes, and treatment of illness anxiety disorder;
Identify the clinical features, causes, and treatment of conversion disorder
(functional neurological symptom disorder);
Explain the psychological factors affecting medical condition;
Elaborate the psychological factors affecting factitious disorder; and
Differentiate between conversion reactions, real physical symptoms and
(malingering) faking.

*Dr. Itisha Nagar, Assistant Professor of Psychology, Kamala Nehru College, University of
Delhi, New Delhi 173
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6.0 INTRODUCTION
Many individuals keep running to the doctor even though there is nothing wrong
with them. These individuals may be preoccupied with their health and body and
in some cases the preoccupation maybe so excessive that it becomes maladaptive
in their daily lives. Soma means body and the common problem associated with
somatic disorders and related symptoms seems to be initially, physical disorders.
However, there is usually no identifiable physical cause for the condition. DSM-
5 lists five basic somatic symptoms and related disorders. They are somatic
symptom disorder, illness anxiety disorder, psychological factors affecting
medical condition, conversion disorder, and factitious disorder. In each, the
individual has an excessive and maladaptive preoccupation with the functioning
of his/her body. In this Unit, we will learn the clinical features, causal factors
and treatment for the five basic somatic symptoms and related disorders.
6.1 SOMATIC SYMPTOM DISORDER
Somatic symptom disorder is characterised by one or more somatic symptoms
that are either very distressing and/or result in significant disruption of daily life.
Refer to the case study mentioned in Box 5.1. Rekha easily meets all the DSM-
5 diagnostic criteria for somatic symptom disorder. She experienced abdominal
pain, nausea and intermittent loose stools for a period of at least one year. Over
the period of one year, Rekha met many doctors, undergone many physical
examinations and tests, and kept a daily record of her symptoms. Her
preoccupation with the symptoms was so distressing that she was finding it
difficult to perform academically. An important feature of this disorder is that
the physical symptoms, such as pain are real even though the clinicians are unable
to find clear physical reasons. There is a new emphasis in DSM-5 on the
psychological and behavioural factors such as anxiety, distress, and time or energy
devoted to the symptoms that seem to be aggravating the severity and impairment
associated with the symptoms. During the time of diagnosis, clinicians have to
specify if the somatic complaints predominantly involved pain.
Box 6.1: Case Study: Somatic Symptom Disorder
Rekha a 20-year-old woman reported severe back pain as a result of a falling
down in her bathroom. After examining her, her doctor prescribed her some
medicines for the pain. Over a few months, the pain settled however, Rekha
developed abdominal pains, nausea and intermittent loose stools. She went
through a full-body-check up, and all her tests came back to normal. She
was then referred to a gastroenterologist who conducted endoscopy that also
came out to be normal, no cause was found for her abdominal pain, loose
stools and nausea. She was sent back by the doctor, but Rekha went to other
doctors and got the tests conducted again. She started maintaining a diary to
keep a record of the severity and intensity of her symptoms. She met with
many doctors again for the abdominal pain and nausea that would come and
go. In one of these visits while waiting for her appointment, Rekha
experienced excessive anxiety and the doctor had to prescribe her anti-anxiety
medicine. She informed the doctors that because of her symptoms and anxiety
she was finding it difficult to perform in college. Rekha had been
experiencing these symptoms for over a period of one year now.
 Somatic Symptoms and
6.2 ILLNESS ANXIETY DISORDER Related Disorders

Illness anxiety disorder (previously known as hypochondriasis) is a condition in

which physical symptoms are either not experienced at the present time or are
very mild. However, the accompanying anxiety focused on the possibility of
developing a serious disease/s is excessive. Illness anxiety disorder is
differentiated from somatic symptom disorder, in that the physical symptom
experienced is mild. In case the physical symptoms are severe and are associated
with anxiety and distress, the diagnosis would be somatic symptom disorder.

6.2.1 Clinical Picture

Refer to Box 6.2 for a case study that reflects illness anxiety disorder. There is an
overlap between symptoms exhibited by Rekha and Rishi. Both are characterized
by fear and anxiety that one has a disease. However, an important difference
between them is Rishi was less concerned with specific physical symptoms but
was more anxious about the idea that he might be ill. Rishi presents a typical
case of illness anxiety disorder. Rishi was preoccupied with having brain cancer,
even when the symptoms were either absent or are minor (vague headache).
People with illness anxiety disorder show preoccupation with normal bodily
functions (e.g. heart beat, bowel movements, blood pressure, sugar levels) with
minor physical problems (e.g. cough, pain, accelerated heart beat, head aches,
joint pains) or with vague and ambiguous physical sensations (e.g. such as ‘aching
veins’, ‘my hair hurt’, ‘my heart is tired’). The mental orientation of the individual
keeps them constantly on alert for new symptoms. They show notable pre-
occupation with digestive and excretory functions. In spite of an inability to give
a precise description of their symptoms many people with the condition would
often give detailed description, because they want to help the doctor find a
“diagnosis” even though there is no real illness. Some keep a detailed chart of
their bowel movements, diet, constipation, and related matters. They are likely
to be updated with information on medical topics and feel certain that they are
suffering from every disease they read or hear about. Many people buy and use
over the counter medicines.They are not malingering that is consciously faking
symptoms.

The care-seeking type of individual with illness anxiety disorder is likely to

come to a mental health professional only after several visits to a general
physician. This is because for the individual, reassurance from the doctor that
she/he is well, only has a short-term effect. This “disease conviction” is a common
feature of both somatic symptom disorder and illness-anxiety disorder. Because
of this, their yearly medical costs are much higher than most of the rest of the
population. The doctor-patient relation is marked by hostility and conflict since
they generally resist the idea that their problem is psychological than physical.

Box 6.2: Case Study: Illness Anxiety Disorder

Rishi is a 45-year-old male engineer presents to a neurologist with multiple
internet searches on the topic of cancer. He states that he “just knows” that
he has a brain cancer. When asked how long this concern has bothered him,
he says “for years I have been thinking that I have tumour growing in my
head.” When asked about relevant symptoms, he is a bit vague, saying “I get
some pain or pressure right here (he points to the left side of his head) but it
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and Eating Disorders
is not there all the time.” Upon asking about his previous visits to doctors,
he replies, “I have had some tests done, MRI and CT scan but the doctors
could not find anything.” He admits to feeling relieved after the results, but
then few weeks later he was restless again, “they must have just missed
something,I think I need another MRI.”Rishi is anxious and increasingly
irritable when the doctor tells him that since he had recently got most of the
tests done and there was no need for another MRI scan. Rishi ends the
encounter by stating that he will “find another doctor who sees my point and
will get me what I need.”

Box 6.3: DSM-5 Criteria for Illness Anxiety Disorder (APA, 2013)
A. Preoccupation with fears of having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in
intensity. If another medical condition is present, then there is a high
risk for developing a medical condition (e.g. strong medical history is
present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily
alarmed about personal health status.
D. The individual performs excessive health-related behaviors (e.g.
repeatedly checks his or her body for signs of illness or exhibits
maladaptive avoidance (e.g. avoids doctors’ appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the
specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another
mental disorder, such a somatic–symptom disorder, generalized anxiety
disorder or obsessive-compulsive disorder.
Specify weather:
Care-seeking type: Medical care including physician visits or undergoing
tests and procedures is frequently used.
Care-avoidant type: Medical care is rarely used.

6.2.2 Statistics
The prevalence of illness anxiety disorder is estimated by the prevalence of DSM-
III and DSM-IV diagnosis of hypochondriasis. 0.1 percent of the general
population is estimated to have illness anxiety disorder (Scarella, Boland & Barsy
2019) . Initially, it was believed that this disorder was more common in the older
adults, however this does not seem to be the case. The disorder is spread fairly
across various phases of adulthood. Anxiety and mood disorders are often
comorbid with somatic symptom disorder. As is the case with anxiety disorders,
illness anxiety disorder and somatic symptom disorder tend to be chronic. Culture-
specific disorders prevalent in India, like dhat syndrome, which is excessive
concern about loss of semen during sexual activity fits with somatic symptom
disorders. Dhat is associated with vague mix of physical symptoms, including
dizziness, weakness, and fatigue. Such ‘culture-bound syndromes’ (Yap, 1967)
are episodic, dramatic, and discrete patterns of behavioural reactions (Lipsedge
& Littlewood, 1979).
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6.2.3 Causal Factors Somatic Symptoms and
Related Disorders

Illness anxiety disorder is a disorder of cognition and perception, with emotional

contribution. Individual’s past experiences with illness (both in themselves and
in others) leads to the development of set of dysfunctional assumptions about
the diseases and symptoms that may predispose a person to developing illness-
anxiety disorder. These assumptions are faulty, unduly alarming, and
pessimistic.Misinterpretations of bodily sensations play a causal role; it follows
the following sequence.
Attentional Bias: Individuals with hypochondriasis seem to focus
excessively on symptoms and have an attentional bias for illness related
information (Owens et al., 2004). They are likely to have biased attention
for any illness related information, event, or image might prove to be a
trigger for the activation of dysfunctional assumptions. They are
hypervigilant about one’s own bodily sensations also.
Activation of faulty assumptions: Illness related information activates the
dysfunctional faulty assumptions about illness and health. For example, a
person may have dysfunctional believe that, “bodily changes are usually
sign of a serious disease”, “being healthy means being completely symptom
free”, “If you don’t go to a doctor right now, it would be too late”, “you
cannot possibly ignore these symptoms”, etc.
Misperception: Individuals may also misperceive their symptoms as more
dangerous than they really are. Research suggests that the individuals believe
that their ability to cope with an illness is extremely low, they see themselves
and weak and unable to tolerate physical effort/exercise.
Physiological Changes: Act of increased focus on one’s body can create
arousal and makes the physical sensations seem more intense than they
actually are. There might be changes in bowel patterns, sleeping and eating
habits, etc.
Behavioural Responses: The individual then engages in repeated
behaviours such as checking, self-examination, taking preventive
medications, reading about the illness etc. These behavioural responses are
reinforced, as the person feels relieved and are thus repeated. This tends to
create a vicious cycle in which the individuals have anxiety about illness
and symptoms.

Box 6.4: Cognitive Theory of Illness Anxiety Disorder

1) Attentional Bias: A person with illness anxiety disorder climbs staircase

and finds his heart racing. Others will ignore this.
2) Activation of Faulty Assumptions: The person misperceives this to a
be a symptom of “hole in his heart”. She/ he begins to have thoughts
like, “if you don’t go to a doctor right now, it would be too late”, “you
cannot possibly ignore these symptoms.”
3) Physiological Changes: Anxiety about developing the illness leads to
activation of autonomic nervous system. She/he starts sweating, heart
beats faster, feels a knot in the stomach etc. It further provides fuel for
her/his conviction that she/he has a “hole in his heart”.
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4) Behavioural response: He or she reads about all cardiovascular diseases
on various internet websites, and chooses to ignore warnings against
self-diagnosis mentioned on the health websites. Visits multiple doctors
and undergoes several tests.
Fig. 6.1: Cognitive-Behavioural Model for Illness-anxiety Disorder
Source: semanticscholar.org
An important question to be asked is: what causes individuals to develop this
pattern of somatic sensitivity and dysfunctional beliefs? First, evidence suggests
that somatic symptom disorders runs in family and may have a modest genetic
component; this component may be non-specific such as tendency to be over-
responsive to stress. Hyper-responsivity may combine with the tendency to view
negative life events as unpredictable and therefore, to be guarded all the time.
Second, individuals who develop this disorder tend to have disproportionate
incidence of disease(s) in their family. These individuals report symptoms that
their other family members may have reported at one time; thus, it is possible
that the individual learned to focus anxiety on specific physical conditions and
illness. Vulnerability to health-illness disorder is usually triggered in the presence
of a stressful life event (e.g. death or illness). Finally, there are important
interpersonal and social influences. A person with illness-anxiety disorder
communicates that, “I deserve more of your attention and concern” and “you
may not legitimately expect me to perform as a healthy person would.” Thus, the
“benefits” (secondary reinforcement) of being sick might contribute to the
disorder.
6.2.4 Treatment
Reassurance and education by mental health professionals has been reported to
be effective. The important point to be noted is that unlike the reassurances given
by friends, family or general physicians, reassurances by mental health
professionals is more effective because it is delivered in a more sensitive manner.
Therapy with people with illness-anxiety disorder is centered around devoting
sufficient time to all the concerns of the patient and engaging in the “meaning”
of the symptoms for the individual. Cognitive-behavioural therapy helps these Somatic Symptoms and
Related Disorders
individuals by focusing on identifying and challenging illness-related
misinterpretations of physical sensations and on showing them how to create
“symptoms” by focusing attention on certain body areas. This awareness allows
individuals to understand that their symptoms were under their control.
Psychoeducation also helps individuals to seek fewer reassurances from the
patients. It also discourages individuals from relating to significant others on the
basis of their physical symptoms alone. They are coached in more appropriate
ways of interaction with others that reduces reliance on the ‘sick role’ and
promotes healthy social and familial adjustment.

Check Your Progress 1

1) What is somatic symptom disorders?
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2) Explain the causal factors of illness-anxiety disorder.
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6.3 CONVERSION DISORDER (FUNCTIONAL

NEUROLOGICAL SYMPTOM DISORDER)
Sigmund Freud popularized the term conversion (conversion hysteria) who
believed that the anxiety resulting from unconscious conflicts was “converted”
into physical symptoms which allowed individuals to release some anxiety without
experiencing it. In DSM-5, conversion disorder is given the subtitle ‘Functional
Neurological Symptom Disorder’. Functional Neurological Symptom refers to
symptoms that result in absence of an organic cause. Most conversion symptoms
suggest that some kind of neurological disease is affecting the sensory-motor
systems, but no organic or physical malfunctioning is present. Conversion disorder
is one of the most fascinating of all mental disorders. How does one go blind
when all visual processes are normal? How does one experience paralysis of
limbs when there is no neurological damage? Figure 6.2 illustrates Freud’s
explanation of conversion disorder.

Unconscious Physical
Anxiety Conversion
Conflict Symptoms

Fig. 6.2: Freud’s Understanding of Conversion Disorder

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6.3.1 Clinical Picture
and Eating Disorders
People with conversion disorder have symptoms of deficits affecting sensory
and/or voluntary motor function that may lead one to believe that the person is
suffering from a neurological problem. Ruling out medical causes for the
symptoms is necessary for making a diagnosis of conversion disorder. Clinician
must be able provide evidence to distinguish between the symptom and recognized
neurological (medical) condition. This is an important criterion to prevent
misdiagnoses of a genuine neurological (medical) condition as conversion
disorder. With advanced technology, misdiagnosis of conversion disorder is much
lower than was the case previously.

Sensory deficits include conversion blindness such as in the case study. A person
might report that she/he cannot see anything and able to navigate about a room
without bumping into objects. Similarly, in conversion deafness, the person would
report that she/he cannot hear anything yet orient appropriately upon “hearing”
his her/name. Thus, there is registration of sensory input but somehow the input
screened from explicit conscious recognition. Other sensory symptoms include:
anesthesia(loss of sensitivity), hypoesthesia (partial loss of sensitivity),
hypersthesia (excessive sensitivity), analgesia (loss of sensitivity to pain) and
parathesia (exceptional sensations such as tingling/heat). One of the most
common motor symptoms is conversion paralysis in which the person may not
be able to walk for most of the time but may be able to walk in emergency
situations such as fire where escape may be necessary. Other motor symptoms
include: tremors, tics, and contractures (rigidity of larger joints). Astasia-abasia
is a condition in which individual has grotesque disorganized walk, both legs
wobbling about in every direction. Speech related conversion symptoms are
aphonia in which an individual is only able to talk in whispers or hoarse
voice.Other conversion symptoms include seizures. Pseudo seizures resemble
epileptic seizures but can fairly well be differentiated; they do not show EEG
abnormalities and do not show confusion or loss of memory afterwards. People
with conversion seizures rarely injure themselves in falls or lose control over
bowels/bladder. There are other wide range of visceral symptoms that are
medically unexplained include lump in the throat, choking sensations, coughing
spells, difficulty in breathing, nausea, vomiting.Finally, conversion reaction cases
of malaria and tuberculosis and pseudo-pregnancies have also been reported.
Refer to Box 6.5 for a case-study. Naina,23-year-old, displays all the symptoms
of conversion disorder.

Box 6.5: Case Study:Conversion Disorder (Functional Neurological

Symptom Disorder)
23-year-old Naina was brought to the emergency department of a hospital.
She reported “suddenly passing out for a couple of seconds at work.” She
stated that she woke up with blurred vision that developed into loss of vision
in both eyes. She also reported an inability to stand due to weakness in her
left leg. While in the emergency department, the patient described seeing
only shadows. She stated that she was generally in good health without
significant medical issues or any history of chronic medical conditions or
surgeries, which was confirmed by her mother. She had no reported mental
health history and no history of stressful childhood experiences (i.e., abuse
or neglect). Naina’s mother reported that her daughter was in a lot of stress
since the last couple of years. Her parents got her married right after
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graduation. She wanted to study more but at that time her parents did not Related Disorders
encourage. Her marriage turned out to be extremely stressful as her husband
would often get drunk and become abusive towards her. She left her husband’s
home one year after marriage and came back to live with her parent. After
facing significant financial difficulties, Naina finally found a job, but her
difficulties were far from over. Her husband sent her a divorce notice and
she recently found out that she was pregnant. On physical examination, the
patient was alert, awake, and oriented to person, time, and place. On
neurological examination, her speech was normal, her pupils were slightly
sluggish but reactive, she was able to see light that was shined into her eyes,
and she demonstrated a full range of eye movement, but there was no visual
acuity to hand motion or finger counts. She had some trouble lifting her left
leg off the bed but was able to walk with assistance. All tests came to be
normal.

Box 6.6: DSM-5 Criteria for Conversion Disorder (Functional

Neurological Symptom Disorder) (APA, 2013)
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the
symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or
mental disorder.
D. The symptom or deficit causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.
Specify symptom type:
With weakness or paralysis, with abnormal movement, with swallowing
symptoms, with speech symptom, with attacks or seizures, with anesthesia
or sensory loss, with special sensory symptom, with mixed symptoms.
Specify if: Acute episode: Symptoms present for less than 6
months;Persistent: Symptoms occurring for 6 months or more.
Specify if: With psychological stressor (specific stressor), Without
psychological stressor.

6.3.2 Statistics
The lifetime prevalence is not known with certainty, highest estimates is 0.005
percent (APA, 2013). Women outnumber the diagnoses of conversion symptoms
by a ratio of 2:1 to 10:1; people from low socio-economic strata are more likely
to develop conversion symptoms (Encyclopaedia of Mental Disorders, 2015)
Conversion symptoms may appear at any time but most people experience their
first symptoms during adolescence or early adult years. Onset is abrupt and
typically follows a major stressor. The course of the disorder may either be
episodic or chronic. In a subsequent episode, the conversion symptom may be
different from the symptom(s) in the previous episode. Comorbid anxiety and
mood disorders are also common. Conversion disorder is at least 2-3 times more
common in women.
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6.3.3 Causal Factors
and Eating Disorders
Although it was earlier believed that there is possibility of genetic influence in
the causality of conversion disorder, twin studies did not support this. There is a
suggestion of overriding influence of psychosocial factors.
Psychoanalytical Theory: Freud developed a psychoanalytical model of
conversion disorder based on the treatment of the classic case of Anna O
(the famous classic case study of Anna O was first discussed in Studies on
Hysteria by Freud and Breur, 1895). He described four basic processes in
the development of conversion disorder. First, the person experiences an
unconscious conflict. Second, since the conflict is unacceptable the conflict
and the resulting anxiety are repressed. Third, the anxiety continues to
increase and threatens to become conscious; the person uses the defense
mechanisms to “convert” the conflict into physical symptoms. This leads to
reduced anxiety which is considered to be the primary goal. Fourth, the
person receives increased attention and sympathy from loved ones and may
also evade certain undesirable tasks. Studies have supported Freud’s
explanation. Researches have concluded that individuals with conversion
disorder have experienced a traumatic event that must be escaped at all
costs. For instance, conversion symptoms such as paralysis of leg were
very common in soldiers to avoid the traumatizing combat situations during
the World War period without being labeled as a coward. In another study,
it was found that most of the patients with conversion disorder had history
of traumatic incidents, including history of sexual abuse, recent parental
divorce/death, and physical abuse. Support for secondary gain comes from
a study that found that adolescents with conversion symptoms rated their
mother as “overinvolved” or “overprotected”. This suggests that the
conversion symptoms may have been strongly attended to and reinforced.

Unconscious Conflict

Repression
The conflict and resulting anxiety is unacceptable thus
repressed.

Conversion of Symptoms: Primary Gain

Anxiety continues to increase and threatens to emerge into
consciousness, the person ‘converts’ it into physical symptoms,
thus reducing anxiety

Secondary Gains
Increased attention, sympathy, and avoidance of difficult
situation/task.

182 Fig. 6.3: Psychoanalytical Theory of Conversion Disorder

 Socio-cultural Perspective: Over the past century there has been an apparent Somatic Symptoms and
Related Disorders
decrease in the incidence of conversion disorder, which suggests a possible
role for socio-cultural factors. The diagnosis of conversion has declined in
western societies such as US and England but has remained more common
in countries that may place less emphasis on ‘psychologizing” distress such
as Libya, China and India. Rates of conversion symptoms are higher in
rural regions where medical knowledge is sparse. Growing medical
sophistication and increased awareness about the defensive function of a
conversion symptom has been attributed to be the reasons behind reduced
incidence of conversion disorder.

6.3.4 Treatment
People with conversion disorder respond well to the cognitive-behavioural
program. An essential element and first in the line of treatment of conversion
disorder is to identify the traumatic or stressful life event. The event may be
present in real or in the memory of the individual. For instance, in case of Naina
(Box 6.5), the traumatic incident was being in an abusive relationship with her
husband, the impending divorce and discovery of her pregnancy. Second, therapist
must educate the family regarding the role of secondary reinforcements such as
attention and sympathy. Naina’s family must be educated against reinforcing her
conversion symptoms through excessive attention and concern. For instance,
her mother was advised against restricting Naina’s mobility because of her
conversion blindness, instead she should encourage Naina to carry activities of
daily living with support from her family members.

Check Your Progress 2

1) According to DSM-5, state the diagnostic criteria of conversion
disorder.
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2) Explain the psychoanalytical explanation of conversion disorder.
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3) How are conversion disorders treated?
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6.4 PSYCHOLOGICAL FACTORS AFFECTING
MEDICAL CONDITION
The essential feature of this disorder is that an individual has a diagnosed medical
condition (e.g. asthma, diabetes, hypertension etc.) that is adversely affected by
one or more psychological or behavioural factors. In this condition, the
psychological or behavioural factors have a direct influence on the diagnosed
medical condition either by triggering or worsening the medical condition,
interfering with treatment or contributing to death or disability. One example
would be a patient with diabetes who is in denial about the need to take medication
to control her/his sugar levels. Another example would be a skin cancer survivor
who routinely forgets to apply sunscreen cream to protect herself/himself.
6.5 FACTITIOUS DISORDER
The essential feature of factitious disorder is falsification of medical or
psychological signs or symptoms in the absence of obvious external rewards
like financial gain or time off work. The motivation for faking of symptoms is
not as clear as in cases of malingering. There maybe no obvious reason for
voluntarily producing the symptoms in oneself, except in some cases it may be
done to assume the ‘sick role’ and receive increased attention. For instance, a
woman introduced alkaline chemicals into her eyes, causing corneal burns, before
visiting an ophthalmologist. In another case a man goes to the hospital
complaining of abdominal pains demanding a surgery for removal of his appendix.
Preliminary examination revealed no apparent medical reason for the pain. Upon
being refused he goes to another hospital with abscess in his stomach. It was
found out that the abscess was self-induced with a kitchen knife. It is essential to
establish that the individual is voluntarily producing the symptoms for the
diagnosis of factitious disorder. This disorder may extend to other members of
the family. An adult may purposely make her child sick, in order to receive
attention and pity given to her as the mother of a sick child. This is factitious
disorder imposed on another.
6.6 DISTINGUISHING BETWEEN CONVERSION
DISORDER, FACTITIOUS DISORDER, AND
MALINGERING (FAKING)
Early observations made by Freud noted that people with conversion disorder
showed very little fear or anxiety that would be expected in a person with a
paralyzed arm or loss of sight. This seeming lack of concern ‘la belle indifférence’
was considered a hallmark of conversion reactions and was included in the
diagnostic criteria in pervious version of DSM. However, it was removed in
DSM IV since latest researches suggest that only 30-50 percent of people with
conversion symptoms showed this ‘lack of concern’ and most actually felt quite
worried and concerned about their symptoms (APA, 2000). Similarly, another
criterion that was present in DSM IV, has been removed in DSM-5. The role of
psychological factors was considered an important criterion for diagnosis of
conversion disorder. It is common to find emotional, interpersonal conflicts or
stressors to precede conversion symptoms. For instance, in case of Naina (Box
6.5), abusive relationship with her husband, financial difficulties, juggling of
job with studies and discovery of her pregnancy preceded the onset of her Somatic Symptoms and
Related Disorders
conversion symptom of blindness. However, occurrence of stressful life situations
is not considered to be a reliable sign and has been removed as criterion for
diagnosis in DSM-5. The presence of a psychological stressor has become a
specifier with the diagnosis; the clinician has to specify whether the symptoms
are preceded or associated with psychological stressor at the time of diagnosis.
People with conversion symptoms can function normally for instance people
with conversion blindness do not bump into objects and those with conversion
deafness may report they cannot hear anything but may orient their head upon
hearing his/her name. In case of emergencies, a person with conversion paralysis
might suddenly get up and run. Some people who experience miraculous cures
during religious ceremonies may actually be cases of conversion disorder. It is
important to rule out a genuine neurological (medical) condition to diagnose
conversion disorder. With technological advances, the misdiagnoses rates of
conversion disorders have decreased over the years.

It might be difficult to distinguish between individuals experiencing conversion

symptoms and those malingering or deliberately faking symptoms. Malingerers
have clear motivation such as trying to get out of legal or work difficulties or
financial benefits. Relative to those with conversion symptoms, malingerers are
fully aware of what they are doing and are clearly trying to manipulate others to
gain something desirable.

Factitious disorder lies somewhere between malingering and conversion disorder.

Although in factitious disorder, the symptoms are under voluntary control, there
is no obvious reason for voluntary producing the symptom except to assume the
sick role and to get increased attention for being ‘sick’.

Check Your Progress 3

1) What are psychological factors affecting medical condition? Why is
it considered to be a somatic symptom disorder?
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2) Define factitious disorder.
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3) How is factitious disorder different from malingering?
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Mood Disorders, Psychotic
Disorders, Somatic Symptoms
and Eating Disorders
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6.7 SUMMARY
Now that we have come to the end of this unit, let us list all the major points that
we have already learnt.
People with somatic symptoms and related disorders are preoccupied with
their health and body and in some case the preoccupation maybe so excessive
that it becomes maladaptive in their daily lives.
Somatic symptom disorder is characterised by one/more somatic symptoms
that are either very distressing and/or result in significant disruption of daily
life.
Illness anxiety disorder is a condition in which physical symptoms are either
not experienced at the present time or are very mild. However, the
accompanying anxiety focused on the possibility of developing serious
diseases is excessive.
Illness anxiety disorder is a disorder of cognition and perception, with
emotional contribution. Individual’s past experiences with illness (both in
themselves in others) leads to the development of set of dysfunctional
assumptions about the diseases and symptoms that may predispose a person
to developing illness-anxiety disorder.
Symptoms in conversion disorder suggest that some kind of neurological
disease is affecting the sensory-motor systems, but no organic or physical
malfunctioning is present.
Sigmund Freud popularized the term conversion (conversion hysteria) who
believed the anxiety resulting from unconscious conflicts was “converted”
into physical symptoms which allowed individuals to release some anxiety
without experiencing it.
The essential feature of factitious disorder is falsification of medical or
psychological signs or symptoms in the absence of obvious external rewards
like financial gain or time off work. The motivation for faking of symptoms
is not as clear as in cases of malingering. There maybe no obvious reason
for voluntarily producing the symptoms in oneself, except in some cases it
may be done to assume the ‘sick role’ and receive increased attention.
6.8 KEY WORDS
Somatic Symptom Disorder: Characterised by one/more somatic symptoms
that are either very distressing and/or result in significant disruption of daily life.
Illness-anxiety disorder: Previously known as hypochondriasis is a condition,
in which physical symptoms are either not experienced at the present time or are
very mild, however the accompanying anxiety focused on the possibility of
developing serious diseases is excessive.
Conversion Disorder: Renamed as Functional Neurological Symptom in DSM-
5, it refers to symptoms that result in absence of an organic cause. Most conversion
symptoms suggest that some kind of neurological disease is affecting the sensory-
motor systems, but no organic or physical malfunctioning is present.
Factitious Disorder:The essential feature is falsification of medical or Somatic Symptoms and
Related Disorders
psychological signs or symptoms in the absence of obvious external rewards
like financial gain or time off work.

Malingering: Faking of medical or psychological symptoms so as to get out of

legal or work difficulties or get financial benefits. Malingerers are fully aware of
what they are doing and are clearly trying to manipulate others to gain something
desirable.

6.9 REVIEW QUESTIONS

1) People with __________ disorders have excessive and maladaptive
preoccupation with the functioning of their bodies.
2) Somatic symptoms and related disorders include which of the following:
a) Conversion disorder
b) Illness-anxiety Disorder
c) Factitious Disorder
d) All of the above
3) Misinterpretations of bodily sensations play a causal role in the development
of ____________disorder.
4) Increased attention and sympathy from loved ones that may reinforce
symptoms of conversion disorder are called ____________.
5) ___________ refers to deliberate faking of physical symptoms in order to
get some clear benefits like financial gain.
6) Individuals with conversion disorder may often display a surprising
indifference about their symptoms- especially when the symptoms to most
people would be disturbing (e.g. blindness, paralysis). This is sometimes
known as
a) Vive la difference
b) Quelle difference
c) La belle indifference
d) Que ce que se la difference
7) Explain conversion disorder from a psychoanalytic perspective.
8) Differentiate between conversion disorder and factitious disorder.
9) Describe the cognitive-behavioural model of illness anxiety disorder.
10) Discuss the treatment of factitious disorder.

6.10 REFERENCES AND FURTHER READING

American Psychiatric Association Division of Research. (2013). Highlights of
Changes from DSM-IV to DSM-5: Somatic Symptom and Related
Disorders. FOCUS, 11(4), 525-527.

Barlow, D.H. & Durand, M.V. (2015). Abnormal Psychology (7th Edition). New
Delhi: Cengage Learning India Edition
187
Mood Disorders, Psychotic Dimsdale, J. E., Creed, F., Escobar, J., Sharpe, M., Wulsin, L., Barsky, A., &
Disorders, Somatic Symptoms
and Eating Disorders
Levenson, J. (2013). Somatic symptom disorder: an important change in DSM.
Journal of psychosomatic research, 75(3), 223-228.

Emery, R.E., & Oltmanns, T.F. (2015). Essentials of Abnormal Psychology (8th
edition). Pearson College Division.

Mineka, S., Hooley, J.M., &Butcher, J.N., (2017). Abnormal Psychology (16th
Edition). New York: Pearson Publications.

Warwick, H. M., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour

Research and Therapy, 28(2), 105-117.

6.11 REFERENCES FOR IMAGES

Cognitive-behavioural model of hypochondriasis. Retrieved 27th July 2019, from
https://www.semanticscholar.org/paper/The-Short-Health-Anxiety-
Inventory%3A-Psychometric-in-Abramowitz-Deacon/49a2b470d5bff1ba8da
532b397fedca1fe048e99/figure/0

6.12 WEB RESOURCES

For a detailed understanding of Freud’s classic case of conversion disorder
of Anna 0;
- http://www.freudfile.org/psychoanalysis/annao_case.html
For more information on factitious disorder imposed on another;
- https://www.medpagetoday.com/psychiatry/generalpsychiatry/48311
Detailed explanation of clinical presentation, causal factors, and treatment
of Functional Neurologic Symptom Disorder;
- https://www.youtube.com/watch?v=bfLv5jMJlOw
To understand illness-anxiety disorder, watch the movie Piku;
- https://www.youtube.com/watch?v=yYr8q0y5Jfg
Answer for Fill in the Blanks (1-6)

(1) Somatic Symptoms and Related Disorders, (2) All of the above (3) Illness-
anxiety Disorder, (4)Secondary Gains, (5) Malingering, (6) La belle indifference

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